Cognitive Behavioural Therapy:

Oppositional Defiant Disorder

Evidence-Based Intervention for ODD- EDPS 674

Alicia Marchini, Sarah Juchnowski & Lindsay Birchall

Agenda

Description of the Intervention - Alicia

Review of Research Basis - Alicia
Overview of the Theoretical Basis - Sarah
General Application - Lindsay
Cognitive Change Tasks - Lindsay
Behavioural Change Tasks - Sarah
Critical Thought of Practical Application - Sarah &
Lindsay

Description of the
Intervention

Description of the Intervention

-

CBT for child conduct problems was developed with the notion that
children display disruptive behavior because of

(a) learned cognitive distortions

(b) cognitive deficiencies
(c) a related tendency to respond impulsively to both external and internal
stimuli

Description of the Intervention

Target Areas:
- To reduce aggressive behaviour
- To increase prosocial interactions
- To correct the cognitive deficits, distortions and inaccurate self-perceptions
- To reduce emotional outbursts, impulsivity, and explosiveness, and ultimately
enabling the child to be more reflective and considerate of how best to respond

Description of the Intervention

Age Range:
-

Initially used with school-age children (5-13 years old)

Adults

More recently used with preschool children

Delivery Format & Accompanying Costs:

-

One-on-One
-

between $120 and $250 for sessions that are 50 minutes or longer

Group
-

between $120 and $170 for sessions that are hour to an hour and a
half long

Description of the Intervention

Training Requirements:
The therapist must be adequately trained in...
-

cognitive behavioural therapy

cognitive restructuring

various therapy techniques to explore personal issues that might be

contributing to the childs defiant behaviour

communication skills

problem solving skills

emotional regulation and anger management

Review of
Research Basis

Review of Research Basis

-

Meta-analytic studies show medium to large effect

sizes (between 0.47 and 0.90) for CBT for children
with conduct problems

CBT has proven to be more effective than comparison

groups

Typically, those who had CBT are more likely to be in the

normal functioning range after the therapy compared to those in other conditions

Limitation of Studies: Often relied solely on parent and teacher report

Kendall and Braswell (1982): Compared CBT, behavioural treatment, and an

attention control condition
-

found that CBT and behavioural treatment were superior to the control
condition and that CBT was slightly more effective

Review of Research Basis

-

CBT leads to an increase in problem-solving skills and self-control, and a

decrease in cognitive distortions and hostile attributions
-

Hypothesized to cause the change in the childs behaviour after the

treatment is completed

However, no studies have shown that these changes are completely

accounted for by the CBT treatment

Review of Research Basis

-

Children of older age (11-13 years old) and with greater cognitive ability are
more likely to benefit from CBT than younger children (5-7 years old) and
less cognitively developed children

Child is less likely to respond to CBT if:

-

s/he has a higher number of conduct disorder symptoms

parent has higher levels of parenting stress, depression, or detrimental

child-rearing practices

the child lives in a single-parent home or is of low socio-economic

status

Review of Research Basis

-

No relationship between the length of the treatment

and the therapeutic outcome for children with conduct
problem

One study found that a longer CBT program

(18 sessions) was associated with significantly
improved behaviour in comparison to a shorter version of the same
program (12 sessions)

Most of the approaches that are examined in studies are typically within a
short time frame (8 and 10 weekly sessions) that are typically an hour long

Review of Research Basis

-

No difference between the outcome of individual and group therapy

formats of CBT and family therapy approaches
-

time and cost advantages of group treatment = might be favoured over

individual treatment

Contradictory Evidence: Group treatment with

children and adolescents with conduct problems
may actually cause the problems to become
worse

Review of Research Basis

-

Many of the studies include children who are referred by teachers, parents,
or peers, or have only mild, undiagnosed behaviour problems

CBT for mild child conduct problems can work, but it has been argued that
they dont actually provide evidence that it does work with actual clients

Suggested that the nature, severity, and number of behaviour problems of

children who are in many of these studies are not significantly different
from those seen in clinical samples

Review of Research Basis

-

CBT has demonstrated beneficial effects with children from outpatient and
inpatient clinical populations, who have multiple diagnoses and are from
diverse ethnic and socioeconomic backgrounds, in various settings

Positive effects were maintained up to a year after the treatment was

completed

This level of generality has not been proven with the many different kinds
of CBT treatment approaches

Evidence for long-term effects (> one year after treatment) is limited

Review of Research Basis

-

Research supports the efficacy of CBT for children with conduct disorders

Influences on CBT:

childs motivation

adherence to treatment

level of knowledge

communication skills

therapists warmth and likeability

Not yet clear which aspects of CBT are effective agents of change and
which are not as effective

Overview of the
Theoretical Basis

History
Behaviourism: Precedes the 1900: Pavlov, Skinner, Little Albert. Focuses on
current, emphasizes overt behaviour, treatment is objective, treatment is
based on empirical research
Cognitive: Derived from the limitations of behaviourism. Began to include
thoughts, beliefs, assumptions, attitudes, memories and fantasies in to
therapy. Bandura (1969) developed the social learning theory, connected our
environment and consequences with cognitive processes. Albert Ellis (1950)
derived from Rational Emotive Therapy, thoughts mediate our behaviour.
CBT: Aaron Beck (1960) developed CBT incorporating both cognitive and
behavioral components. Beck put great importance into ones internal dialogue.

Rationale and Change Process

Behaviourism:
Follows scientific method,
Belief that behaviour is observable, measurable and easily evaluated,
Talk is not valuable
Change comes through stimulus control and reinforcement
Cognitive:
We make sense of our situations through thoughts, which affects how we
behave and feel
Dysfunctional thinking causes dysfunctional behaviour
By identifying new ways of thinking
Change comes through analyzing, organizing and reframing thoughts

Cognitive Behavioural Therapy

Combinations of Cognitive and Behavioural therapy

Cognition, emotion, behaviour, and physiology all interact together with the
environment
By examining all these aspects you can in turn develop the best treatment
plan
CBT is dynamic and all-encompassing
Many change tasks under CBT makes it the most popular and empirically
researched mode of psychotherapy.

Application

Symptom Review
Angry/Irritable Mood
Argumentative/Defiant Behaviour
Vindictiveness
Developmentally inappropriate
Noncompliance, defiant and disruptive behaviours
Actively refusing to comply with adult requests and rules
Oppositionality-disobedient behaviours toward authority
Negativistic and hostile behaviours
Aggression (verbal threats and physical acts)
Excessive arguing with adults
Poor Emotional regulation
Deliberately trying to annoy others or upset others, or being easily annoyed by others
Blaming others for your mistakes
Being spiteful and seeking revenge
Swearing and using obscene language-saying mean or hateful things when upset
Property destruction
(APA, 2013; Hamilton, 2008; Steiner & Remsing, 2007; webmed.com)

Implications of Symptoms

Individuals typically do not recognise symptoms in themselves

instead they justify their behaviours as a response to unreasonable circumstances or
demands
Significant disturbance in social, academic or occupational functioning
Problematic relationships and interactions with others
Circular Causality of dysfunctional interactions
Dysfunctional family interactions
Difficulty making and keeping friends-peer rejection
Difficulty at work with supervisors and authority figures
Poor school work and performance - school dropout
Antisocial behaviours
Suicide, anxiety, depression, substance use
Impulse control problems

(APA, 2013; Hamilton, 2008; Steiner & Remsing, 2007; webmed.com)

Etiology
Single cause is unknown and unlikely
Symptoms increase with age
The gradual stacking of factors contributes to the
development of ODD

Risk Factors:
SES, culture, prenatal (smoking, toxin exposure, poor nutrition, neglect),
familial cluster of disruptive behaviour disorders, unresponsive parenting
practices, attachment related, parents likely to have similar difficulties with
self-control, emotional regulation, mood stability, one parent diagnosed
with psychiatric disorder, marital difficulties)

(Steiner & Remsing, 2007)

Early Intervention & Prevention

Early Intervention: the earlier the intervention process can begin, the
more likely it is to succeed

Possible prevention of more problematic behaviours and the typical

progression of ODD (e.g. later developed CD)

Early interventions can minimize the damage to relationships (e.g. child

and family distress)

More intensive treatment is necessary if the onset is early and the

severity is great

(Steiner & Remsing, 2007; Baker & Scarth, 2002)

Individualized Intervention Plan

Multiple change tasks within Cognitive and Behavioural Therapy
Tasks should be chosen based on individual symptom presentation and
individual capacities
Plan should target all domains of dysfunction
Skills should be as developmentally and age appropriate as they can be

(Steiner & Remsing, 2007)

Cognitive-Change Tasks
Identifying and Testing Automatic
Thoughts
Decatastrophizing
Reattribution
Redefining
Decentering
Thought Stopping
Distraction
Three-column technique
Maladaptive Assumptions

Cognitive Change Processes

Awareness of clients cognitive content or stream of thought in their
reaction to an upsetting event
View thoughts as hypothesis-rather than facts-so clients can recognize
dysfunctional or irrational thought patterns
Substitute accurate judgements for inaccurate judgements
Gather feedback to inform clients of whether the changes they made
have resulted in the desired outcome
Self-Management/Problem-Solving/Awareness of Cognitive Schemas

(Tuscott, 2010, Wedding & Corsini, 2014)

CBT & ODD

Focus on
Communication
Problem Solving Skills
Impulse Control
Anger Management
Main Skills
Problem Solving
Cognitive Restructuring

Children often have cognitive skill gaps

and cognitive distortions affecting these
areas (Baker & Scarth, 2002)

Problem Solving
May be collaborative: involving
others who the challenging
behaviour arise with (parents, peers,
teachers)
May be group: students presenting
with similar symptoms and difficulties
in similar areas
May be individual
(Bierman, Miller, & Stabb, 1987; Frey, Hirschstein, &
Guzzo, 2000; Green et al., 2004, Linseisen, 2008)

Group Problem Solving:Second Step

Second Step problem Solving Model
1. Identify the problem
2. Brainstorm solutions
3. Evaluate solutions by asking, Is it safe?
Is it fair? How might people feel? Will it
work?
4. Select, plan, and try the solution
5. Evaluate if the solution worked and what
to do next

Social Learning Theory & Modeling

Ideal for practicing social problem solving in school
settings
Students practice problem solving model using
hypothetical situations
Role Plays, Dramas & Comedic scenes: offers
emotional distance
Video clips
Puppets, character play (younger children)
Ideal size 4-8 members
Same sex membership is better
2x a week for 5 weeks: 50 min training sessions
Use of contingency-based systems

(Bierman, Miller, & Stabb, 1987; Frey, Hirschstein, & Guzzo, 2000)

Group Problem Solving:Second Step

Watch video clip

Characters demonstrating positive and
negative behaviours
Ask group questions/discussion
What set the character off? What did
you see happen? What were the
consequences?
Identify details: voice tones, facial
expressions, hand gestures, defensiveness,
hostile posturing, angry eye contact
Children with ODD often do not see all the
consequences of their actions
especially with peer relationships
or issues of respect and trust

Group Problem Solving: Second Step

Use group process to help in sticky situations
For example: What do you think we need to do
about Joeys behavior, guys? What do you think
our choices are?
If Joey continues to break Rule #2, our group cant
[pick something positive that is planned or a group
reward that could be given].
Im wondering how the group can help?
Give verbal praise to the suggestions that are
beneficial, while trying to ignore or minimize the
negative or threatening comments.
(Linseisen, 2008, p.9)

Group Problem Solving: Second Step

Use humor to defuse negative comments or actions
Well, Freddy, punching Joey in the face is an option.
However, then, you would be in even more trouble with
the group than Joey is.
Great idea?

(Linseisen, 2008, p.10)

Cognitive Restructuring
Redefining a problem: can facilitate change when our conceptualization of the problem was
preventing change
Mobilize a patient who believes a problem is beyond their control
Stating problems in terms of behaviours over which we have control
Can make a problem more concrete and specific
Stating problems in terms of the patient's behaviors

ODD
Individuals often attribute their problem to the actions of others - The problem is out of their control May teach individuals with ODD that the problem can be navigated if they redefine it-take accountability
and responsibility for their behaviours
(Truscott, 2010; Wedding and Corsini, 2014)

Cognitive Restructuring
Automatic Thoughts
Thoughts are accessible, powerful and habitual
Gather data on specific thoughts
Test validity and meaning through direct
evidence and logical analysis
Identify cognitive distortions
May uncover logical inconsistencies,
contradictions, errors in thinking

Thought Stopping

Part of Automatic Thought process

Breaking a chain of thoughts that tend to
escalate into distress, particularly anxiety
Client identifies sequence of thoughts- then
attends to those early in the process
Anxiety or frustration provoking activity is
undertaken, to practice interrupting the
chain

(Truscott, 2010; Wedding and Corsini, 2014)

Cognitive Restructuring
ODD
Identifying thoughts that contribute to escalation. Breaking a chain of thoughts using
thought stopping. Stop anger, frustration, anxiety that may escalate into aggressive or
hostile behaviours. Building tolerance through practice. Pair with redefining the problem
and taking responsibility for ones actions.

Behavioural - Change Tasks

Homework
Hypothesis testing
Exposure Therapy/Interventions
Behavioural Rehearsal/Role Play
Diversion Techniques
Activity Scheduling
Graded-Task Assignment
Relaxation Based Interventions

Response Prevention
Operant Strategies
Social Skills Training
Time-Out
Successive Approximation
(Shaping)
Contingency Based (Token
Economies)
Modeling

Token Economy Systems

Token Economy Systems (TES)

Individualized programs in which the child receives tokens in return for appropriate
behaviour. These tokens include a range of reinforcers (money, privileges, or
objects)
TES are among the most successful programs in applied psychology
TES can help to improve academic and social skills, attention, speech, drug
addiction, self-care, and disruptive behaviours

ODD

Typically used to increase compliance, disruptive behaviour and academic

Contingent teacher praise or reprimands
Token economy systems
Response cost
Time out from positive reinforcement
Self-management

Relaxation Based Interventions

Relaxation Interventions
Techniques include: breathing, refocusing attention, increasing body
awareness, exercises, meditation, progressive muscle relaxation, visual
imagery, and variations of these.
ODD
Typically used to target anger and tantrum like behaviour
Decreases physiological arousal
Techniques include relaxation, distraction and self-instruction

Behavioural Change Processes

Reinforcement
Prompting
Stimulus Control
Setting Events

Critical Thought:
Practical
Application

Age of Application
Younger clients

May need more concentration on

behavioural techniques
Do not have as rich language
Developmentally Egocentric
(trouble taking others perspectives)
Lack of insight

Older Clients

May need more concentration on

cognitive techniques
Have more cognitive abilities for
verbal techniques
May not buy into behaviour
techniques

Cognitive and Language Issues

CBT assumes the client has strong understanding of language. Clients must be able
to analyze and process their own thoughts to a certain extent for cognitive therapy to
be affective.

Links between behaviours and feelings are more easily recognized by individuals
with higher IQs and verbal ability.

CBT is feasible in some of these circumstances

EX) for individuals with cognitive impairments with specific modifications.
Such modifications may include: drawings, visuals, repetition, slowing down
sessions, over teaching and an increase in explicit teaching.

Cultural Issues
Aspects to consider:
Socio-economic status
Ethnic groups
Family dynamics

Lack of Insight
Blame game
Do not hold themselves accountable
Blame others for their circumstance ex) They
MADE me mad.
Believe their actions are warranted based on what
they see as unrealistic expectations
Theory of mind difficulty
Often manipulative, quick to exploit others
Strong need to gain power, therefore power is the
ultimate reinforcer

Co-Morbidities

(Hamilton, 2008; APA, 2013 p.466)

ODD is highly comorbid with other disorders:

Attention-deficit/hyperactivity disorder (ADHD)
Mood Disorders
Depression
Anxiety
Conduct Disorder
Substance use problems
Specific Learning Disorders

Symptoms of ODD can be difficult to distinguish from other problems

Treating other mental health conditions may help improve ODD symptoms
It may be more difficult to treat ODD if these other conditions are not evaluated and
treated appropriately (may worsen ODD symptoms)
CBT strategies should fit individual symptoms (e.g. impulse control, attention)

Non Compliance (Linseisen, 2008)

Interventions that increase compliance are imperative

lead to decreased disruptive behaviours
Bottom step on the ladder
Without compliance, motivation and willing participation you will not be able to work on helpful
change tasks, no matter how evidence based they are

Considerations:

Children that are non compliant and oppositional may sabotage your efforts to help them
If they are forced to engage in the intervention process, their participation will be low
If they do not believe their behaviour is a problem, their participation will be low
Children with ODD often crave and thrive on negativity and conflict
Oppositional behaviours may be reinforced by adult and peer attention, contributing to
non-compliance

Compliance Building (Linseisen, 2008)

Give commands and provide consequences effectively

Delivery of requests using a firm but quiet tone of voice, using
statement form (not question form)
Requests should be specific and delivered within 3 ft of the student
Establish eye contact before making requests
Post 4 or 5 positively behaviourally stated rules for the student
Teacher movement in the classroom provides more supervision in
the classroom
promotes detection of problem behaviours earlier
Increased potential for rewarding positive behaviours more
frequently
Use of Mystery Motivators as positive reinforcers in the classroom
Recognize and praise children for good behaviour

Relationship Building

Relationship building is imperative

Therapist must build an alliance with the child
Building a relationship with youth with ODD can take time and
require great patience

Often youth are disliked and disregarded by adults

Identified as problematic or defiant within the system
The older the youth, the more challenging

We need to meet youth where they are at

without pushing to make changes in their behaviour or to
connect with the worker faster or more intimately than the youth
can manage
By working with the youth at their own pace the worker can gain
trust and promote security and stability in the relationship.
After a relationship is established: work on skills
(Linseisen, 2008; Steiner & Remsing, 2006)

Parent Participation
Considerations:
Parents of children with ODD may be contributing to the
problem behaviours (parental mental health issues, dysfunctional
family dynamics, substance use problems, inconsistent discipline, lack
of supervision, harsh discipline, poor emotional regulation, neglect,
abuse, etc.)

Children with ODD are relentless and relationships with

parents are strained
Interventions should involve positive family interactions

Adherence to recommendations may be low: consider CBT

models including homework

Parents will likely need ongoing supports to maintain their

mental health: Counselling, Parent Training, support groups

(mayoclinic;Linseisen, 2008;
Hamilton, 2008; Steiner &
Remsing, 2006)

Parent Training
Should Include:
Mental Health provider experienced in
treating ODD
Parent-Child Interaction Therapy or
Systemic Family Therapy
Individual and Family Therapy
Behaviour Modification Therapy
Collaborative & Cognitive Problem
Solving Training
Social Skills Training
Building Resiliency

(mayoclinic;Linseisen, 2008; Hamilton,

2008; Steiner & Remsing, 2006)

Possible Behavioural Parent Training Tasks

Recognize and praise positive behaviours

Model positive behaviours
Avoid power struggles
Set limits and enforce consistent reasonable consequences
Set up a routine
Build in quality time together
Work with your partner: ensure consistent and appropriate
discipline procedures
Enlist supports from teachers, coaches and other adults
Be prepared for challenges early on: Extinction bursts
Replace empty threats with clear, calm, concise instructions

(mayoclinic;Linseisen, 2008; Hamilton,

2008; Steiner & Remsing, 2006)

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